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Features of the organization

of medical-evacuation actions
at liquidation of consequences
of earthquake

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The medical aid organization at earthquakes
is defined by scales of accident and
quantity of the suffered people


1. -

The characteristic of operational and tactical and medical
conditions in an earthquake zone
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Bases of the organization of medical-evacuation actions.


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The characteristic
of operational and tactical and
medical conditions
in an earthquake zone

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Conditions in a seismic center influence: intensity of fluctuations of a ground,

presence of secondary factors, seismic stability of designs, density of
placing of people, readiness of the population to actions at earthquake.
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Probable consequences of earthquake: landslips and collapses; destructions

of dams and dams; cracks and destructions of road coverings, the
railways, bridges; disappearance of underground water sources and
occurrence of new reservoirs; infringement of joints and ruptures of
pipelines; fires; paralysis of an industrial and social infrastructure,
infringement of functions of life-support systems; shelter deprivation.
!

The basic danger collapsing buildings!

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Features of medical conditions in earthquake areas:

One-stage occurrence of a considerable quantity of the victims needing rendering
of urgent medical aid, evacuation and hospitalization.
Losses in medical shots of local public health services.
Destruction of medical institutions.
Duration of extraction of victims from under blockages.
Destruction of roads, absence of enough of traffic controlers and indexes on the
remained roads.

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The basic medical consequences of earthquake:

Great number of victims and necessity of carrying out of emergency medicosanitary
measures in the shortest terms.
Difficult sanitary-and-hygienic conditions, because of failure of systems of power
supply and water supply, the water drain, a congestion and migration of the big
weights of people, territory infection with toxic components, etc..
Infringements of mentality at victims and liquidators.
Disorganization of management by public health services in disaster regions,
human and material losses in its various links, not allowing to liquidate
earthquake consequences own forces.

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Adverse factors of operational and tactical and medical conditions:

Suddenness and mass character of receipt of the amazed.
Inaccessibility of medical institutions (destruction of access roads), adverse
weather conditions, season and days).
Great number of children, women, persons of elderly and senile age among
victims.
Threat of repeated influence of amazing factors.
Low level of preparation of practical surgeons in questions of medicine of
accidents.
Complexity of structure and weight of damages.


:
, 1948 . - 27 . , 55,5 . .
, 1988 . - 25 . , 31 . .
.., .. (1994 .):
50-80 % .
50-75 % , .
- 30-40 % ,
.
20-30 % , .

At earthquakes:
Ashkhabad, 1948 - 27 thousand persons were lost, 55,5 thousand persons are injured.
Armenia, 1988 - 25 thousand persons were lost, 31,0 thousand persons are injured.
Nechaev E.A., Farshatov M.N. (1994):

Mental trauma at 50-80 % the person in a disaster zone.

Mechanical trauma at 50-75 % the person which are in a zone of buildings.
Sharp diseases and aggravations of a somatic pathology - at 30-40 % the person which
has remained without a roof over the head.
Prostudnye diseases at 20-30 % the person which has remained without a roof over the
head.

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1988 . ( ..,1990 .) : 5-20 %,
10 %, 35-40 %, 25-80 %,
2-5 %, 50 %.

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: 1- , , 2-
, 3- .

Structure of defeats at earthquakes.

In Armenia 1988 (Shaposhnikov .., 1990): a trauma of a skull of 5-20 %, a
breast and stomach trauma 10 %, a trauma of extremities 35-40 %,
traumas 25-80 %, the combined traumas 2-5 %, a
syndrome of long pressing 50 %.

Plural and traumas often become complicated a bleeding,

shock, a purulent infection.

Risk factors of death: on 1st place a trauma, incompatible with life, on

2nd traumatic shock, on 3rd sharp .

 15 % -
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About 15 % of victims with heavy mechanical damages of a basin and the bottom
extremities perish from heavy complications of the sharp period of the
traumatic illness one of which is fat embolism.

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2-3 ;
70 . ., 30 ;
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;

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Risk factors fat embolism: traumatic shock of 2-3 degrees; hypotension at

systolic arterial pressure below 70 mm hg, 30 mines lasting longer; heavy
mechanical trauma of bones of a basin, shin and hip; destruction of soft
fabrics of extremities and smashing of bones; transportation of the patient in
the sharp period of traumatic illness from one medical institution in another.

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Since 2-3 days after a mechanical trauma of a stomach, a peritonitis as most

the death plausible reason, comes out on top.
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The structure of losses is supplemented with the infectious disease arising as

consequence of sharp infringement sanitary-conditions of life of life
around accident or places of time moving. The first place is occupied with
gastroenteric diseases and illnesses from overcooling.

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Action of extremely low temperatures on a human body is accompanied by

development stress-induced of an immunosuppression.
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Dehydration, the reasons and conditions (deficiency of water, blood loss,

plasma loss).

Absence in zones of accidents of forces and means for rendering

the ophthalmologic help.
.. ., 1992 .:

,
. 6853
(1988 .) 1140 .
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Gundorova R. A, etc., 1992:

Victims at earthquake have polymorphism of an ophthalmologic pathology
and its communication by the combined influence of damaging factors,
and including with powerful stress. Among 6853 victims at earthquake in
Armenia (1988) defeats of an organ of vision are revealed at 1140 persons.
The majority of them have passed survey at the ophthalmologist after 2 weeks
after accident when time for rendering of the high-grade help has been
missed.


, , 1994 .: 50-80 %
() .
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, 3-4
12-14 .
- .
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.
10-15 %
5- % - - .

Psychological reactions and mental frustration

, Farshatov, 1994: At earthquake mental traumas are observed at 50-80 % of all population
in a zone (region) of act of nature.
The strongest group mental reaction, involuntary horror, panic.
Psychoinjuring factors at earthquake come into effect not at once, and for 3-4 days and even for 1214 day when against overfatigue and an organism exhaustion work capacity sharply decreases,
there are psychological failures and psychopathological reactions. Specific displays of defeat
of people are psychoneurological stresses.
Depression, neurotic reactions and asthenic conditions can be expressed in the form of
displeasure by administration and absence of trust to actions of doctors. Expressiveness of
adverse psychogenic reactions decreases at a publicity establishment on all aspects of a
situation and carrying out of purposeful medicamentous therapy.
Approximately 10-15 % of victims need hospitalization in psychoneurological medical institutions
and not less than 5 % - in out-patient-polyclinic conditions.


( , 1988 .):

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Defects of work of civil medical divisions (by experience of liquidation of

consequences of earthquake in Armenia, 1988):
At expansion in field conditions there was no division of tents on functional mission;
There was no correct medical sorting;
At a syndrome of long pressing novocain-blockades weren't carried out and measures of
the prevention of sharp nephritic insufficiency weren't applied;
Simultaneous work of all doctors, without the schedule, the exhaustion affected quality and
labor productivity;
Presence of tactical errors in the absence of the uniform approach to treatment;
Evacuation was conducted chaotically, without weight of damages;
The medical documentation and the account of delivered medical property wasn't
conducted.

Bases of the organization

of medical-evacuation actions.

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Not the medicine, and administration stars in
business of the help by the wounded man and
the patient on war theater.

(.. )

..
N.I. Pirogov

22

Not the medicine, and management stars in business of the help by the victim at
emergency situations

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Medical-evacuation actions - the complex of medical, organizational and technical actions

including: search, gathering and evacuation (transportation) in medical formations (division)
and establishments, rendering of necessary medical aid, treatment, rehabilitation.

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This complex should provide timely reception amazed high-grade medical aid, preservation
of life by it and recovery of health.

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All medical actions which needs amazed, are distributed on stages. At first the help
appears on a place where defeat is received, and then - in medical formations
and establishments in process of advancement by the way of evacuation of the
definitive treatment amazed to a place. Thus, medical aid is divided into some
kinds and combined with evacuation.

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If at evacuation of the amazed medical sorting and a direction in profile (specialized)

establishments or divisions such form of stage-by-stage treatment is called as
system of stage-by-stage treatment with evacuation to destination is
carried out.


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Indispensable operating conditions of system of stage-by-stage treatment are:

- observance by all participants of uniform principles of rendering of medical aid and
treatment;
- presence of enough of corresponding cots at all stages and evacuation directions;
- presence of the short and accurate medical documentation providing sequence
and continuity of medical-evacuation actions.


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Depending on concrete conditions the quantity of stages can be shown to a

minimum and then all medical actions are spent in one establishment
(treatment system on a place).

General characteristic of stages of medical evacuation

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As stages of medical evacuation medical formations and establishments of all

ministries and the departments involved in liquidation of consequences of an
emergency situation can be used.
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Their work will be organized by uniform rules!

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Creation and deposition of the formalized registration and accounting documents

should be one of rules.

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The stage structure usually includes the divisions providing:

reception, registration and medical sorting of the amazed;
sanitary processing, deactivation, decontamination and disinfection of clothes,
footwear and other property;
isolation amazed, representing danger to associates;
medical aid rendering;
hospitalization and treatment (at the stages rendering qualified and specialized
medical aid);
diagnostic researches;
placing amazed, subjects of the further evacuation.

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Medical aid kinds: the first medical aid, the pre-medical help, the first medical
assistance, the qualified medical aid, specialized medical aid.
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The first medical aid the kind of medical aid including a complex of the
elementary actions, carried out directly on a place of defeat or near to it as it should
be itself and mutual aid, and also participants of a wrecking, including medical
workers with use organic and make-shifts.
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Pre-medical medical aid the kind of the medical aid, which action supplement the
first medical aid. It appears the medical assistant or the staff nurse in the center
(zone) of defeat with use of organic medical property.

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The first medical assistance the medical aid kind, including the action, carried out by
the doctor (or under instructions of the doctor), as a rule, at a corresponding stage of
medical evacuation. The given kind of the help render in the full or reduced volume. At the
reduced volume on a place of rendering of the first medical assistance carry out urgent
actions refusal from which threatens amazed with destruction or occurrence of heavy
complication. Actions which can be compelled are delayed, and actions which can be
rendered at a following stage, spend later.

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Typical medical actions of the first medical assistance: a stop of an external bleeding;
maintenance of cardiovascular system; resuscitation; punching or a trachea intubation;
imposing of a hermetic bandage at an open pheumothorax; a puncture of a pleural cavity;
an immobilization of a head, a neck, a backbone, extremities; intravenous introduction of
medical products and others.

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The qualified medical aid the kind of medical aid including treatment-and-prophylactic
actions, carried out by doctors-broad specialists surgeons, therapists.

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Actions of the qualified medical aid are divided on urgent and actions which at adverse
conditions can be delayed.
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If the amazed need the further treatment, and consequently also evacuations they are
given evacuation assignment.
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The qualified surgical help provides elimination of the heavy conditions menacing to life
caused by damage, carrying out of actions for the prevention of the subsequent
complications and providing the further evacuation.
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It is reached by realization of various operative interventions.

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The volume of the help and treatment methods depend on concrete medical conditions. It
is necessary to aspire to expansion of volume of the help.
3 .


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The first group of actions of the qualified surgical help is the interventions applied
under vital indications:
definitive stop of an external and internal bleeding;
complex therapy sharp , shock and a traumatic toxicosis;
asphyxia elimination;
surgical processing and mending of wounds at an open pheumothorax,
laparotomy at wounds and the closed traumas of a stomach with damage of an internal;
operations at bladder and rectum damage;
amputation at separations and destructions of extremities;
operations apropos infections;
cranial trepanation at wounds and the damages accompanied by pressure upon a brain.


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The second group of actions of the qualified surgical help

urgent interventions of the first stage - the operations which delay leads to obviously
heavy complications:
Fistula imposing over a pubis at urethra damage;
Imposing of unnatural back pass at damage of sites of the rectum which has been
not covered with a peritoneum;
Amputation at ischemic defeat of an extremity;
Primary surgical processing of wounds with considerable damage of soft fabrics.


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The third group of actions of the qualified surgical help

urgent interventions of the second turn - the operations which delay under condition
of early and regular application of antibiotics not necessarily leads to
development of dangerous complications:
Surgical processing of wounds of the soft fabrics which are not subject to operative
treatment;
Processing of strongly polluted burn surfaces;
Suture at scrappy wounds of the person;
linkage of teeth at crises of the bottom jaw with defect.


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Specialized medical aid the kind of medical aid including a complex of exhaustive
medical actions, carried out by doctors-experts of a various profile in specialized medical
institutions (branches) with use of special equipment.
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Distinguish surgical and therapeutic specialized medical aid.

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Principal views of the surgical specialized help: neurosurgical, ophthalmologic,

otolaryngologic, stomatologic, traumatologic, akushersko-gynecologic, angiosurgical.

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Principal views of the therapeutic specialized help: toxicological, radiological, psychoneurologic.

Some main principles of rendering of emergency medical aid

at various kinds of defeats

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Possibility of expansion of volume of medical aid at the expense of mobile divisions

(formations), groups of strengthening and groups of specialized medical aid (traumatologic,
neurosurgical, ophthalmologic, otolaryngologic).

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Besides the surgical grant it is necessary carrying out of psychopharmacological preventive

maintenance by all amazed, correction of mental infringements and elimination of additional
psychological pressure by timely and full anesthesia, carrying out of psychotropic therapy
by sedative means, small doses of energizers and nootrops.

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It is necessary to train beforehand surgeons and therapists in skills of diagnostics and

rendering of the urgent otolaryngologic help at the first stages of evacuation.

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Necessity of participation of the ophthalmologist for survey, sorting of victims, since a

place of accident and further at all stages of evacuation.
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At rendering of any kind of medical aid should be: the phenomena directly menacing to
life are eliminated at present, heavy complications are warned, is provided
transportations without essential deterioration of a condition.


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Attempts of reduction of duration of a pre-hospital stage at the expense of reduction of

volume of medical aid amazed with a trauma of a stomach and their fastest evacuation
aren't always justified. The overwhelming majority such amazed are nontransportable.
For their rescue it is necessary to render the qualified surgical help in immediate
proximity from a defeat zone. Surgical brigades of constant readiness and the
helicopter-operational are for this purpose necessary.

Medical evacuation

!

Evacuation from a seismic center on the subsequent stages

shouldn't be end in itself!
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Medical evacuation - carrying out (export) amazed from the center, area (zone) of an
emergency situation and their transportation to stages of medical evacuation for the
purpose of timely rendering of necessary medical aid and maintenance of productive
treatment.

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Evacuation is the compelled action and is fraught with deterioration of a condition of

victims.
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At the same time, fast, sparing, well and correctly organized evacuation promotes the
fastest and most to a complete recovery of health of victims.

Medical evacuation
:

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Main principles of medical evacuation:

observance of recommendations of the doctor of a sorting brigade on sequence of
transportation of victims;
carrying out of special preparation of victims to long evacuation, realization of preventive
medical actions;
maintenance of necessary equipment, warming in a way, a food;
supervision over a condition of the victims, expecting evacuation transport, and
maintenance of functions of vitals;
modification of spent treatment and of the sorting conclusion at change of a condition
evacuated.

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The basic ways of medical evacuation: carrying out and export.

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To export of victims are applied: manual carts and sledge, pack animals, animal-drawn,
automobile, water, aviation, a railway transportation.
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Vehicles:
special (medical, sanitary transport),
adapted (fastenings for a sanitary stretcher or sitting for easily amazed),
passenger the general using (with places for transportation in a prone position are
equipped and sitting).

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Places of loading amazed on transport should is out of a zone of infection and fires but as it
is possible more close to the defeat center.
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Gathering points are in these parts created, loading platforms are prepared, there is a medical
aid, medical sorting of the amazed is spent.

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Loading of the transport following in stationary , it is expedient to carry out amazed,

identical on character and defeat localization (it considerably reduces interhospital
transfers and transportations).

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Before loading amazed on each vehicle the list evacuated in duplicate (one copy with the
signature of the person responsible for evacuation, remains in loading point, and the
second follows with amazed to destination) is made.

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Before transport sending it is necessary to check presence of medical documents at each

amazed.

Some rules of sequence of loading and placing of the amazed

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To transport in horizontal position it is necessary all victims who are in an

unconsciousness, with a backbone trauma, after resuscitation, with infringement of
function of external breath, with operating system of transfusion of liquid medical
products.
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Being in an unconsciousness, in the presence of spasms, possibilities of occurrence of

vomiting are necessary for placing on the first circle, others hard amazed not above
2nd circle, lying amazed with transport tires and plaster bandages on the top circles.

10-15 (
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At transportation in cars the head end of a stretcher should be turned towards a cabin and
is on 10-15 sm above foot (for reduction of longitudinal moving of a body during
movement).

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Medical sorting - the major action providing the accurate organization of rendering amazed
medical aid and their evacuation.

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It gets special value at one-stage receipt on stages of medical evacuation of considerable

number of the amazed.

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Medical sorting is a distribution amazed on groups to signs of needs in homogeneous

treatment-and-prophylactic and evacuation actions according to the medical indications,
the established volume of the help at the given stage of medical evacuation and the
accepted order of evacuation.
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Medical sorting should be continuous, successive and concrete.

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It is spent on the basis of three sorting signs: danger to associates, a medical sign
(degree of needs in medical aid, sequence and a place of its rendering), an
evacuation sign (necessity, sequence of evacuation, a type of transport and
position on transport).

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At earthquake it is necessary to allocate streams of victims:

- victims with ;
- having signs of purulent complications;
- the persons demanding the highly professional traumatologic help, including damages
of a skull and a brain, eyes, an ear, a throat, a nose;
easily suffered.

Problems of medical supply at liquidation of consequences of earthquake

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(
1:5000, 0,9% 10 % , 5 % 10 % , 3
% 5% , 0,5 %, 1 % 2% ,
, 2 % , 1% 3% ).
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Problem of medical supply of formations and establishments (difficultly predicted expense

of medical products, surgical threads, dressing means and other medical property).
Problem of supply and manufacturing of sterile medicinal solutions (solution of a furacillin
1:5000, 0,9 % and 10 % solutions of sodium of chloride, 5 % and 10 % glucose
solutions, 3 % and 5 % solutions of sodium of a hydrocarbonate, 0,5 %, 1 % and 2 %
solutions of a novocain , a solution of Ringer, 2 % a solution of a trimecain, 1 % and 3 %
solutions of potassium of chloride).
Problem of reception of the distilled water, sterilization of solutions for injections, dressing
means, operational linen and medical tools.

The basic lines of system of medical-evacuation actions at liquidation

of consequences of earthquake
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two stades of actions for liquidation of medical consequences;

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gradual escalating of medical forces and the means which are carrying out rendering of
medical aid;
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interaction of medical formations of a various accessory;

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the unified character of the surgical help to the victim, the field surgery based on the
beginnings with position realization about necessity of the organization of as much as
possible early rendering by the victim of the first medical aid, their prompt evacuation
in the medical divisions approached to a zone of disaster and probably fuller coverage
by their qualified surgical help;


;

subordination of main principles of the organization of emergency medical aid to the

population in extreme situations to the general principles of health protection and
rendering of medical aid to the population;
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basing of system of medical actions on an existing network of treatment-and-prophylactic

establishments.